Depression

I was hospitalized (for the second time) on a psychiatric unit from May 9 to August 12, 2016. As I alluded to in previous posts, my time on the psychiatric unit was incredibly valuable with so many radical improvements physically and psychologically. I was allowed to use my laptop during off-unit privileges and I wrote extensively – in notes to myself and messages to friends – about the changes and insights that developed during my hospitalization. I occasionally posted on this blog during that time, but most of my writing remained unposted because there was simply too much to process so quickly. I had expected to maintain my positive trajectory following discharge so I had planned to revise and post my writing here shortly after leaving the hospital.

But now, trying to retrospectively capture the enthusiasm and excitement in my old writing feels forced and hollow. Over the past few months, most of the major improvements have deteriorated as rapidly and radically as they arose, and I have been left to watch my mind disintegrate once again. As this decline has progressed, my despair has been considerably amplified by the knife-sharp awareness of just how much I had gained in hospital and how much I am in the process of losing.

So I have avoided writing altogether, instead posting my drawings and my poems and my photos which have taken on much darker undertones in recent weeks. It would, perhaps, be something of a delusion to think that anyone has noticed the change in the nature of my posts. Very few people visit this blog, and of those that do, I doubt that most of them have the patience or interest to read my writing in its entirety. My closest friends have often criticized my writing in my correspondence to them as being too lengthy, too distressing, or too rigorously academic. I have no reason to believe that my writing here would be perceived any differently by an online audience.

Is sharing these thoughts a desperate self-pitying bid for attention? No. Because any attention granted in response to such a plea would be quite superficial and quite meaningless, so it would be illogical to seek that kind of attention. No. This is simply an honest account of my current experience. I value authenticity above most other personal attributes. To me, authenticity – and her sister trait, vulnerability – represent extraordinary courage: the courage to “endure the sharp pains of self-discovery” in the process of understanding one’s own experience, and the courage to share this experience with others despite the risk of invalidation and rejection that plague every potential human interaction.

One of the most confusing patterns that I’ve noticed as my depression has worsened during recent months has been the withdrawal of many of my closest friends. Formerly close relationships have become strained, distant, and detached. I have been trying very hard to understand what has contributed to this widespread withdrawal. At first I believed that I was the common denominator, and I spent many sleepless nights trying to figure out what is so wrong with me that my friends are no longer willing to engage with me in ways that feel genuine. But now I wonder if it is less a problem with me, and more a problem with them. Perhaps the common denominator is their inability or unwillingness to tolerate the excruciating intensity of the sadness, loneliness, hopelessness, and meaninglessness that dominate my psychological landscape.

Unlike previous episodes of depression, my current experience is also dominated by anger, a towering and terrifying RAGE. Often this rage is directed at myself, rage like drops of blood attracting a predatory frenzy of depressive sharks. Sometimes this rage is directed at the world, rage like hand grenades exploding in the face of societal adherence to oppressive conventions that marginalize so many broken people. And sometimes this rage has no target, rage like a forest fire burning at the whim of wind and weather, the crackling searing heat omnivorous and destructive. But fires are essential for regeneration of forest vegetation. Maybe my rage is the first step towards some kind of psychological reintegration.

Direct feedback from my friends and my own observations during interactions with them suggests that humans are fundamentally distressed by intense emotions, especially anger, in themselves or in others. I am not sure why emotional intensity is so uncomfortable for them, and they have all been unable to coherently articulate the reasons behind their discomfort. But I wonder about several possible contributing factors.

1. I think many people retain a false and judgmental belief that intense emotion is necessarily the result of some kind of distortion or magnification on the part of the person expressing it. This belief may be the internalized result of an affect-phobic culture. This belief may also reflect the fragility of human egos finding comfort in a comparative notion that the absence of such painful intensity in themselves represents their own superior emotional regulation.

2. I think many people also believe that the expression of intense emotion necessarily implies a desire or expectation to reduce that intensity. Almost without exception, people automatically respond to someone else’s pain with advice and suggestions intended to help fix the problem or suppress the emotional intensity. I think this tendency reflects an unwillingness to accept their own powerlesssness. People seem largely unable to understand how their aggressive attempts to be helpful actually eclipse their capacity to empathize.

3. And I think that most people are afraid of truly empathizing with intense pain because doing so would require acknowledging their own innate potential to experience pain beyond their control. Such an acknowledgment would shatter illusions of personal agency. When somebody like me calmly and rationally outlines the meaninglessness and futility of life when all sense of purpose, satisfaction, and self-worth have been stripped away, people are forced to re-evaluate the framework they use to justify their own worth and purpose – they must then confront the threatening truth that these ideas are often built around tenuous and artificial self-delusions.

I have always tried very hard to avoid overwhelming my friends with the negative aspects of my experience. I have shared the fact of my depression with them, but I have intentionally minimized the severity of it, I have openly and deliberately invalidated myself in conversation with them, and I have often completely avoided mentioning my most distressing experiences. These behaviors represent my conflicted and evidently unsuccessful attempts to be authentic yet avoid provoking their discomfort. But as my depression becomes more debilitating and more painful, it becomes increasingly difficult for me to hide it. And as the intensity of my pain becomes more evident to them, the more uncomfortable they become and the more they withdraw from me. I have seen their faces fall, I have felt the cooling of the air between us, I have heard their static silence oozing through the speaker on my phone whenever I allow them to see a fraction of my truth. They cannot face my reality, so they retreat and withdraw. Their silence becomes deafening, and their absence suffocating.

[Translation: He who fights with monsters should look to it that he himself does not become a monster.
And if you gaze long into an abyss, the abyss also gazes into you].

Depression is a monster. And I feel like an abyss. My existence is intensely painful. This pain is all-consuming, inescapable, and terrifyingly rational. I move from day to day accompanied by more distress than most people have ever known or even have the capacity to imagine. When I stop protecting them from me and allow them to glimpse the true extent of my hopelessness, they are horrified to find themselves gazing into the abyss. And they are even more horrified to find the abyss gazing back at them with a familiar face.

I never knew I never knew that everything was falling through That everyone I knew was waiting on a cue To turn and run when all I needed was the truth But that’s how it’s got to be It’s coming down to nothing more than apathy I’d rather run the other way than stay and see The smoke and who’s still standing when it clears Everyone knows I’m in Over my head Over my head – Over My Head (Cable Car) (The Fray, 2005)

My fellow patients on the psychiatric unit are certainly an interesting cast of characters. Of course I wonder about their stories, I wonder what combinations of pain and circumstance and bad luck (and maybe good luck too?) have brought them here. And for all of them, I harbor a detached empathy, an impersonal hope that they can find their way back to their lives. Even so, I try as much as possible to avoid interacting with the other patients. Most of the time I lack the energy for superficial conversations. And I lack the imagination required to use small talk as a shield from the reality of our situation, the fact that we’re all here on the psych ward, that the locked unit doors are under video surveillance, that we’re all under the influence of the many multicolored pills we swallow every morning. My personal rainbow is red, white, and yellow.

I avoid the other patients too because many of them seem to have lost appropriate social inhibitions along the way, often spewing rude and abusive comments that I get so tired of deflecting and increasingly less willing to tolerate. I also get so tired of other patients asking my name, mispronouncing it, mispronouncing it again when I correct them, and eventually just inventing their own bastardized version of my three easy syllables because my name is too much effort for them. And finally, I avoid the other patients out of a desperate instinct of self-preservation – it takes all my strength to remain focused on my own therapeutic goals, and I just can’t afford to be distracted by caring too much about anyone else on the unit. They are here for their problems, I am here for mine – I can’t forget that.

Though I intentionally maintain this safe detachment from the other patients, I cannot help but watch them all with involuntary interest. There’s The Watchman, always lurking at the end of the hall where the lights are dimmest, his dark restless eyes seeming always to be fixed on me, the hood of his black sweater drawn up around his face like the cowl of a vigilant monk. And old Abraham Lincoln – the resemblance really is uncanny – who never seems to leave the spindly chair by the courtyard windows, his lanky body folded up like an oversized praying mantis. Sleeping Beauty, who emerges from her room only rarely and wears her hospital gown like an elegant cascading dress, floating through the hallways with a radiant self-absorption and a distended pregnant belly preceding her quiet footsteps. Eyebrows, whose bushy black brows dominate his placid face and create an expression of perpetual confusion, his eyebrows dancing up and down to punctuate each spoken word, each sideways glance, each bite of food. Santa Claws, with his leering eyes and scraggly food-littered beard, his leather Harley Davidson jacket and fingers decked out with silver skulls, hands so grotesquely swollen that the rings are nearly buried by the bulging flesh, his long and fungally discolored toenails scraping the floor like ugly claws. Serene, with coiffed gray hair and deep grooves running down from the corners of her mouth like a ventriloquist’s dummy, who complains endlessly about the smell of dust, who marches back and forth across the same few feet of floor holding her diaper in place with both hands, often shouting at nobody in particular, “I just want peace of mind! You have peace of mind! Why can’t I have peace of mind? I used to be a spiritualist, you know. I used to be able to enter the spirt world but I can’t anymore. I just want peace of mind!” (We all ignore her outbursts, no-one here has peace of mind). And there’s The Howler, heard but never seen beyond one brief glimpse of a bare torso twisted across a mattress on the floor of the high-obs room, his chillingly inhuman screams filtering through the corridors at all hours of the day and night.

All of these patients I regard with a carefully cultivated detachment. Except for Cody.* I am drawn to him with a startling and shattering compassion that slices through my cautious distance and makes my heart ache. I don’t know why. Perhaps it is his physical resemblance to my brother – same endearingly disheveled hair, same ice-blue eyes, same roguish youthful handsomeness, same lingering hint of unwashed masculine musk. Perhaps it is my own selfish desire to inhabit such an effortlessly narrow-hipped, broad-chested body, the masculine alignment of his bones and muscles so achingly appealing to my girl-trapped brain.

Or perhaps it is that Cody’s demons are more outwardly obvious than most other patients on the ward. He cannot hide his battles with monsters I can’t even imagine. His blue eyes rarely register the real world around him, focused instead on high invisible shelves that he stretches up to reach, invisible barriers on the floor that he probes carefully with dirty bare feet, invisible companions sitting in the empty chairs beside him. All of his movements are slow and tense and deliberate, coherent only in a separate world the rest of us can’t see. And all these movements are narrated by his ceaseless whispering, too quiet to hear the words themselves, just a soft susurration like butterfly wingbeats. Occasionally he is interrupted from these explorations of his invisible world – quite suddenly his entire body stiffens, his head snaps to the side, his mouth stretches in a soundless scream, and a series of tremors rattle through his rigid slender body until – just as suddenly – his body stills, he blinks, looks around dazedly, and resumes whispering.

Perhaps I am drawn to Cody by a powerful but unfamiliar protective instinct – a parental sort of protectiveness, perhaps, although in my case neither maternal nor paternal – an irrational hope that if I could just fold him in my arms and shield him from the world (real and invisible) then I could somehow absorb his pain and leave him whole. Even if it killed me. I wonder if this is how my parents feel when they watch my struggle with depression. I wonder if I underestimate how hard this might be for them, how strong the instinct to protect and shelter, if this boy I barely know can draw such fierce protectiveness from my cautious heart.

But I think, more than anything, I am drawn by Cody’s smile. I have seen it only once, walking past him in the hallway. He was engaged in a repetitive pulling motion, as though he were dragging something heavy up towards his chest, his whispers seemingly directed at the evidently irksome object. As I walked closer, his hands stilled and his whispers faded and his bright blue eyes met mine – and I could see the crystal clarity suddenly alive behind the blue. The ghost of a smile tugged at the corner of his mouth – a tiny crooked smile climbing up and crinkling the corners of his eyes as his head dipped in a respectful nod of recognition. A thready filament of connection hovered between us for a moment – the flash of recognition in his eyes heartbreaking and unmistakable – until suddenly the thread snapped, his eyes dropped downwards, his whispering resumed, and just like that – with all the finality of a guillotine blade – his moment of awareness was abruptly severed.

So now whenever his path crosses mine, I find myself searching his face for that crooked smile, that awareness, that flash of recognition, searching with a desperate selfish reckless caring that takes my breath away. I see you, Cody. I’m here. I know you’re there too. But he remains lost in his world of whispered things.

But he left me one more smile. After breakfast one morning, he shuffled into the dining room two hours late but I’d asked the nurse to save his tray. He attempted to eat at first but quickly lost track of his fork, his gaze drifting off, his whispering more fervent, and began lifting invisible items up off the floor. As he leaned down, the bunching of the muscles in his back was visible through the gap of his hospital gown – hard knobs of vertebrae protruding between the trailing strings he didn’t finish tying – that gap in his gown a green-rimmed sliver of heart-wrenching vulnerability. Then his attention shifted to his paper menu and, slowing picking up a nearby pencil, he began writing. Eventually he abandoned his writing and drifted away – whispering and shuffling – and I could see the scrap of paper he’d left behind. It was a list of names, I’m not sure who they are, scrawled in the overlarge and messy handwriting of a child. Near the bottom, the “r” in Tyler – with unexpected whimsy – was drawn as a stick figure with arms outstretched. Below the names, he wrote two statements: “walking sucks run” and “40 like steves as you say” – not quite nonsense, not quite sense – followed by a pencilled crooked smile. I see you, Cody. I know you’re there too.

*Not his real name.

A perfect smile is more appealing but it’s funny how My shit is crooked, look at how far I done got without it I keep my twisted grill, just to show them kids it’s real We ain’t picture perfect but we worth the picture still – J Cole (Crooked Smile, 2013)

This is my brain. You’ll have to take my word for that though – it looks so ordinary, doesn’t it? Just an ordinary brain – a vast and beautiful ecosystem of interconnectivity. The extraordinary complexity of it is somehow diminished by the flatness of the image, the deceptive simplicity of the gently undulating sulci and gyri.

A nurse leads me from the psychiatric unit down through the guts of the hospital to the MRI room. Scrub-clad staff shuffle softly past us, diligent and busy, unnoticed aboveground but vital to the round-the-clock function of this teeming facility. We pass the steamy laundry room, the fragrant kitchen, several silent storage vaults. The hallways are cast in pale fluorescent light with an occasional dull orange flash from the elevator displays. A stripe of faded blue tape splits the corridor in half, faint dusty footprints crisscrossing back and forth across the dividing line. We have entered an entirely different world down here – a dim basement fairy-tale world of medical equipment and quiet footsteps.

MRI stands for magnetic resonance imaging, a technique developed in the 1970s that uses magnetic fields and radio-frequency waves to create cross-sectional images of organs and tissues. I am getting an MRI of my brain as part of the work-up for chronic depression, to rule out possible organic causes such as inflammatory disorders, cerebrovascular anomalies, or brain tumors. All of these are very unlikely, but because my depression has been unusually severe, prolonged, and resistant to conventional treatments, my in-patient psychiatrist wants to explore the possibility of rare underlying causes.

So the nurse rolls my body into the machine and I lay as still as death – movement artifact can interfere with image quality – wth my head in a plastic cage, cranium cushioned by foam pads on either side. The loud mechanical clunking from the machine becomes a visceral thudding din that seems to penetrate right down to my bone marrow. I can force my body into stillness, but I cannot quell the restless activity in my mind as it dredges up fragments of conversations from what feels like a thousand lifetimes: who I was and who I am, things I’ve lost and things I’ve locked away, wise voices echoing in a chamber of despair.

“She is probably the best student I have worked with over the past 15 years I have been in academia.”

“People with great abilities naturally have great successes and great failures.”

“You expect people to behave in logical and predictable ways. But they don’t. Not everything is logical. And that expectation creates a lot of frustration and disappointment for you.”

“You wear your emotions on your sleeve, McMurray. You can’t hide your anger and frustration, even when it’s directed at yourself. That much emotional intensity is intimidating.”

“You are a solution that’s just waiting for a problem.”

“Remember we once talked about finding your way out of the darkness of a great forest?”

“That’s not how it works here, princess…”

Today my psychiatrist tells me that the MRI showed no abnormalities. I ask to see the images – not because I don’t believe him, but because I want to see this brain of mine. On the screen it looks so… grey and calm and normal. I had expected, at least, that the machine would have somehow captured the racing chaos of my thoughts, like headlight streaks in a long-exposure photo of a busy city during rush hour. Or I thought perhaps the image might show a rim of necrotic blackness devouring the grey matter, some kind of visible sign of the darkness in my mind. Or I even half-expected to see a nest of snarling demons ensconced in their cerebral lair, ghoulish grins like candid mugshots of the pain that grips my brain.

Staring at my brain on the screen, this restless mind once more starts sifting through the debris of recent conversations. The technician who said, “What’s a nice girl like you doing in a psychiatric unit?” The nurse who asked me about my suicidal intentions and then, after I described my list of lethal methods and the pros and cons ascribed to each, said, “You look really good right now. You seem calm and coherent.” The friends who have expressed their confusion and disbelief when I describe the severity of this depression, “But you sound so normal! You seem like your usual self!” Even my out-psychiatrist who admitted that I seem so composed and articulate during appointments that he initially questioned why we were considering readmission to hospital. My outward composure – sometimes the hard-won result of energy I can barely muster, sometimes simply the only way I know how to be – seems to mask the intensity of my internal pain. And this MRI image feels the same way: it looks perfectly ordinary, composed and coherent, while the agony remains entirely invisible.

Remembering and sequencing the events of today becomes an overwhelming challenge, my mind trudging grudgingly through the heavy fog that clouds those recent memories. The last few days and weeks and even years are stacked haphazardly, an inseparable scatter of all things past.

More cruelly, depression amputates the future. Tomorrow and next year are equally incomprehensible. This missing sense of future is deeply unsettling. It is like losing your peripheral vision – only when it’s gone do you realize, with horror! – how casually you took it for granted, how much it used to guide your behavior and perception, and how without out it you feel lost in a narrow and distorted world.

I have also seen these wrinkles in time described by people with terminal physical illnesses. Most eloquent of these descriptions was written by Paul Kalanithi in the days leading up to his death from lung cancer:

“Verb conjugation became muddled. What tense was I living in? The future tense seemed vacant and, on others’ lips, jarring. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.”

The relentless suicidal ideation that accompanies depression seems, in many ways, very similar to the last months of a fatal physical disease. To outsiders, the most salient difference between those two is the illusion of choice.

I think that a coherent sense of future can also be a casualty of gender dysphoria, especially for those of us with uncertain transition goals and unpredictable transition outcomes.

“I have had a hard time visualizing my future, as either female-perceived or male-perceived. Needless to say, this is a bit of a dilemma, as it can create the sense of moving into an enigmatic, inconceivable oblivion. Now, I don’t think it’s healthy to focus too much on the future, but I do think it’s normal to have some sort of future projection of yourself to hold onto – and I think that’s something that transgender people are plagued with – with not being able to visualize their future self during uncertain times, particularly when they are considering medical intervention.” – gendermagik

The point where depression and dysphoria intersect is a terrifying discontinuation of the mental and the physical, an inescapable Möbius strip of mind and body locked perpetually in the painful present tense.

The broken clock is a comfort, it helps me sleep tonight Maybe it can stop tomorrow from stealing all my timeI am here still waiting, though I still have my doubts I am damaged at best, like you’ve already figured out – Lifehouse (Broken, 2007)

“You do not get the time back. Whatever time is eaten by a depression is gone forever. No matter how bad you feel, you have to do everything you can to keep living, even if all you can do for the moment is to breathe. Wait it out and occupy the time of waiting as fully as you possibly can. Hold on to time.” – Andrew Solomon (The Noonday Demon, 2001)

I had been dealing with depression for several years before I started exploring gender transition options. Of course, the distressing incongruity between my female body and my brain’s non-female body map had been extreme and persistent since puberty, but I tried so hard for so long to suppress those feelings, to attribute them to the body image disturbances that characterize anorexia nervosa or dismiss them as an unusual form of gender-centered vanity. So it was not until more recently – thanks in large part to perceptive suggestions from an observant friend – that I learned about gender dysphoria and started considering transition in a personal context.

When I first became aware of these options, I felt an immediate and expansive euphoria, an ebullient optimism that inflated me with such promising possibility. I believed that I had finally found The Answer to so many of my life’s uncertainties. I believed that transitioning – in a straightforward black-and-white line, from ugly A to perfect B, from female to male (whatever I thought those words meant then) – was The Solution that would fix all of my problems.

Buoyed by this excitement I began researching transition options, poring obsessively over online trans forums and frantically downloading research papers from PubMed. Very quickly I encountered cautionary statements – in scientific studies and trans peoples’ own stories – urging those of us considering transition to have realistic expectations about how transition may affect our life and reminding us that transitioning will not solve every problem.

“Overall, participants’ evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. It was described as a ‘‘challenge’’ or a ‘‘long and difficult road’’ that was worth taking because of its positive implications on future life, at the end of which not everything was different or better without limitations.” (Rupin 2015)

“Don’t expect transitioning to solve all of your problems. Transitioning is not a panacea – it won’t solve all of your problems. If you were prone to anxiety before coming out, you’ll probably still have to deal with it afterwards. At some point in my transition, I came to terms with the fact that living as my true gender wouldn’t magically fix everything. And it felt really good to let go of that impossible expectation.” – Annika

So I started to examine my own expectations about transitioning. This process began very gradually, my original optimism tempered but preserved. But as I delved ever deeper into myself, as I came to recognize – with a terrifying emptiness – that I do not have any cognitive sense of gender identity (just the physical distress associated with female anatomy), and as my long-standing depression spiralled ever further out of control, I started asking myself with a haunting and repetitive urgency: how much does gender dysphoria contribute to my depression? How much can I expect transitioning to alleviate this complex distress? These questions quickly gathered a frightening momentum, eliminating one by one every hopeful expectation I had about transition, culminating in a crushing avalanche of doubt about whether my gender dysphoria was even worthy of continued acknowledgment.

So often I would reach the end of the day and reflect on the past 16 hours, wondering what would have been better if I had lived the day inside a male body. Usually the answer that I gave myself was that very little would have changed, perhaps a few accidental mirror glimpses – always that initial flash of confusion as my brain works to reconcile reality with expectation – those mirror glimpses might have been less unpleasant, sure, but nothing else would have been any better. So why bother with transition then? Why bother with all this gender nonsense at all?

But in the moments when depression loosens – ever so slightly – its death-grip on my mind, in the moments when I feel a lucid clarity open up like a window to the world, I wonder if perhaps I underestimate how deep this dysphoria extends, if I underestimate how extensively the brain numbs itself to daily pain after a lifetime of unabated agony. And in these moments I can relive the day with more precision, sailing through the same sequence of events, but this time in a masculine vessel. It seems a lot would have been better.

On the squash court –
The squeak and shriek of sneakers on shiny varnished floor –
I could have worn shorts without feeling so self-conscious of my girl hips, I would not have been so painfully aware of my small shoulders dwarfed by the broad backs of male opponents, I would not have felt such desperate pressure to overcompensate with wins to prove that I deserve to play among men.

Standing outside in the summer sun –
The far-off chirp of cheerful birds and the low buzz buzz of busy bees –
I could have escaped my sweat-sticky sweater, an all-season mask concealing the feminine swell of my chest, and I could have instead felt the sun kiss the skin on my bare arms, I could have let my eyes wander as they wished without so consciously averting my gaze from the girl-shaped shadow on the ground.

In the shower –
Warm rivulets of water draining down over all the parts that I pretend do not exist –
I would not have had to cloak myself in darkness, I could have soaped my bristly legs without thinking automatically that I should shave them, and stepping out afterwards I could have wrapped the towel around my waist and seen my face and my bare chest in the mirror and not had to look away.

Driving in my car –
My hand on the shift stick and wind breezing in through the open window –
I would not have had to angle the rearview mirror just so to avoid that quarter-slice of girl-face when I glanced upwards, I would not have had to tug my jacket down low enough to hide the width of my hips in the seat, and I could have sung along more freely with the radio with a deeper voice vibrating through the lines of my jaw.

Pulling on my pants in the morning –
The rustling of fabric and the brisk zip of the fly in chilly pre-dawn dimness –
The flatness of the crotch would not have been such a mocking emptiness, the snugness of the pants over my hips and thighs would not have been such an excruciating reminder, and when I looked down I would have seen a man in jeans instead of a girl in men’s jeans.

Sitting typing like I am now –
Quiet clickety clack, clickety clack, rat a tat tat –
I would not have to feel the tight X of bra straps across my back, I would not have to notice how my wrists and fingers on the keyboard seem so slight and feminine, and I would not have to be afraid of seeing my face reflected back at me in the laptop screen.

With all of that, how is it possible that I still doubt whether I should transition? Such doubt this is! It only seems to multiply as my mind paces the same well-worn path through the same worn-out questions. This doubt is an aggressive beast that feasts on self-reflection.

“Do you suppose,” the Walrus said,“That they could get it clear?”“I doubt it,” said the Carpenter,And shed a bitter tear.– Tweedledee (Through the Looking Glass and What Alice Found There, 1871)

I recently spent three weeks hospitalized in a psychiatric unit for treatment of depression. In clinical terms, I have severe chronic treatment-resistant major depressive disorder, a mouthful of words to describe a debilitating disease that has affected the trajectory of my entire adult life. My pharmaceutical history reads like a drug compendium, A to Z by generic name: aripiprazole, bupropion, caffeine, citalopram, clonazepam, desvenlafaxine, dexamphetamine, lisdexamphetamine, lorazepam, mirtazapine, oxazepam, trazodone, tryptophan, venlafaxine, vortioxetine, zolpidem, zopiclone. Over the past year in therapy, I have turned my soul inside out looking for answers, finding only a buzzing hive of angry stinging questions. But effort means nothing in the face of this monster. My brain just keeps attacking itself over and over, with ever shorter reprieves between recurrent nightmare episodes.

My time in hospital was frustrating, necessary, and marginally helpful. I worked hard to create realistic expectations for myself after discharge and I was prepared to tolerate the distress arising during the initial readjustment to real life. But coming home from hospital has been unlike anything I have ever experienced before… I feel empty, hollow, completely gutted, broken beyond repair with a skull full of ugly scars, so far beyond hopeless that there are no words to describe this degree of detachment and despair. Since then I have been going through the motions of daily life, but that is truly all they are – mechanical motions performed perfunctorily to pass the time. I still adhere to the hospital schedule because it is the only structure I can cling to in the shattered remnants of my world: breakfast at 8:00, lunch at 12:00, dinner at 17:00, one pill at 19:30, another at 21:00. And when I’ve reached the end of each endless day, I have to fight through the night to snatch a few hours of disturbed and broken sleep.

I feel like I held on to my last shred of sanity while I was in the hospital, because I was focused on the short-term goal of getting discharged and because a smoldering filament of rage kept me connected, somehow, to the outside world. But now I have no goals, no anger, nothing, I’m just drifting in a completely meaningless void while the world keeps moving around me.

This depression feels like a brain tumor that has been growing for six years, slowly at first but ever faster as the malignancy multiples, gradually taking up more and more space inside my head and slowly choking off pieces of who I am. It has strangulated my motivation, eroded my energy, killed my capacity for hope. All I am left with now – and for how much longer I don’t know – is the capacity for gratitude, and a raw and feral intelligence caught in a leg-hold trap, thrashing ferociously and trying to chew off its leg to escape but unable to gnaw through the bone. And this toxic neoplasia continues growing faster than my acceptance of it, an escalating arms race, a Cold War in my brain.There are no surgical options for treatment, no chemotherapy, not even any palliative means to ease this excruciating pain.

My psychiatrist, my sister, my friends – friends! such an inadequate word to describe these people that I love so fiercely – they encourage me so often to find things to be hopeful for. I try – I do – I try so hard – with infinite gratitude for their kindness and support – but I cannot manufacture authentic hope. It’s like being naked in a winter wind, trying to imagine what warmth feels like – even if you can conjure up the most vivid memory of hot summer sun, it will not prevent you from freezing to death.

I think the most powerful emotions are gratitude and hopelessness.They both have the ability to eclipse all semblance of rational thought. They both leave me breathless in the wake of their intensity. And the two can coexist in a devious kind of harmony, like brilliant fireworks bursting in an unrelenting darkness.